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Kingdom of Saudi Arabia, King Abdulaziz university, Jeddah
Hernia Of The Umbilical Cord
Dr. Mazen O. Kurdi (FRCSI)Ass. Prof. pediatric surgery
Prof. Dr. Yasir S. Jamal (FRCSI, FICS)f f d lProf. of pediatric & plastic surgery
President, Saudi association of ped. Surgeryd d f f lVice-president, Saudi scientific ass. of plastic surgeryHead, division of pediatric surgery
Umbilical cord hernia
Introduction:Introduction:It is a simple failure of complete It is a simple failure of complete return of the midgut to the peritonealreturn of the midgut to the peritonealreturn of the midgut to the peritoneal return of the midgut to the peritoneal cavity which usually occurs around cavity which usually occurs around thth 1010 kkthe the 10 10 week.week.
Umbilical cord hernia…cont
It is uncommon .It is uncommon .Small defect (less than Small defect (less than 2 2 cm) .cm) .Located at the umbilicus with the Located at the umbilicus with the umbilical cord extending from itumbilical cord extending from itumbilical cord extending from it.umbilical cord extending from it.Covered with a sac.Covered with a sac.Contains only the midgut . Contains only the midgut .
Umbilical cord hernia…cont
These patients might have ese pat e ts g t a emalrotation , although it is not
ll f i i lusually a cause of intestinal obstructionobstruction.
( Michael D.Klein / Grosfeld etal. pediatric surgery sixith edition 1157-1171,2006)
Umbilical cord hernia…cont
W t bili l l & DWet umbilical cord
clamp. & sep. cord
Dryness
Normal Umbilical Cord
Normal Umbilical Cord
How to differentiate?How to differentiate?
Cogenital Abdominal wall defectsDefect site sac contents frequency Associated
anomaliesoutcome
Omphlocele (lat. Fold)
umbilicus yes Liver , intestine ,spleen, gonad
common Chromo. & cardiac
Good (dep. on the
associated anomaly)gonad anomaly)
Omphlocele (cephalic
Fold)
Sup. umbilicus
yes Liver, intestine
rare Cardiac,sternal cleft ,central
t d di h
poor
tendon diph.
Omphlocele (caudal Fold)
Inf. umbilicus yes intestine rare Bladder extophy,impe
rforated
fair
rforated anus&episp
Umbilical cord hernia
umbilicus yes intestine unusual uncommon good
Gastoschisis Rt. umbilicus No intestine common Intestinal atresia
good
Ectopia cordis
thoracis
Midline sternum
No heart rare cardiac poor
Umbilical cord hernia…cont
Management:Counseling and reassuring the parentsCareful examination to determine the
following:Diameter(<2cm)Diameter( 2cm)Status of the content
• Reducible• Reducible • Irreducible which might be due to adhesions
or membrane.
Umbilical cord hernia…cont
h f d dThe type of management depends upon:If the base is narrow & there is short protrusion f h d i f hof the contents Reduction of the contents
& Simple ligation of the sac .
Umbilical cord hernia…cont
If the base is Broad & there is long epithelialized protrusion around the umbilicusepithelialized protrusion around the umbilicus Initial reduction , clamping & immediate or later repair with cosmetic umbilicoplastyp p y
Umbilical cord hernia…cont
If the contents are not reducible or if there i bl di M d i lis bleeding Mandatory surgical intervention .
Umbilical cord hernia…cont
The contents are easily reduced by holding the sac upwards & gently milking the bowel into the peritoneal g pcavity.The fascia can always be closedThe fascia can always be closed primarily & a cosmetic umbilicoplasty is nea l al a s feasible hich mightis nearly always feasible which might be immediate or late (OR).
Umbilical cord hernia…cont
Different presentations:
Umbilical cord hernia…cont
Care should be taken as the content of the sac is the midgut with or without
AppendixAppendix.Patent omphalomesenteric duct.Adhesions between the bowel and the sac as it will be seen in one of ourthe sac as it will be seen in one of our cases.
(Catrena Borgna - pignatti etal. Journal of pediatric surgery,30:1717-1718,Des.1995)
(David M. sherer .Gynecol obstet Invest 51:66-68,2001)
Umbilical cord hernia…cont
The umbilical abnormality can be di d i h i f d lidiagnosed with certainty after delivery , but ,antenatal ultasonography , can be h l f l d hhelpful in determining these abnormalities such as
Hernia of the umbilical cord OmphaloceleOmphaloceleTeratoma of the cord.
Umbilical cord hernia…cont
This gives a indication forThis gives a indication for distal clamping of the cord to avoid injury of the bowel
til th b b i tt d d buntil the baby is attended by the pediatric surgeonthe pediatric surgeon.
Umbilical cord hernia…cont
In KAUH 14 cases of umbilical cord hernia seen & treated over the last 10years (1997-2007).y ( )Retrospective review of antenatal ultrasonography did not indicate theultrasonography did not indicate the presence of the abnormality.All of the cases were near term ranging between 34-38 weeks.
Umbilical cord hernia…cont
12 of which had reducible content while the other 2 cases presented by irreducibility due to adhesions in oneirreducibility due to adhesions in one of them and septum that prevent the reduction in the other one which led to hemorrhagic fluid upon trial ofled to hemorrhagic fluid upon trial of the reduction.
Umbilical cord hernia…cont
8 of the cases were managed by a simple d ti f th t t d li ti freduction of the contents and ligation of
the sac. (short neck ,narrow base)
Umbilical cord hernia…cont
4 f h h d id b &4 of the cases had wide base & long epithelialzed protrusion , were managed by repair of the umbilicalmanaged by repair of the umbilical hernia ( mayo s repair & cosmetic umbilicoplasty )
2 i di2 immediate .2 late closure.
Umbilical cord hernia…cont
2 cases needed immediate surgical intervention in the form of Repair & umbilicoplasty due to irreducibility which was due to:
AdhesionsAdhesions. The presence of septum.
Umbilical cord hernia…cont
Despite of that most of the patients p pwith hernia of the umbilical cord were having malrotation but thiswere having malrotation, but , this was not an indication to explore any of our patients.
( Grosfeld etal. pediatric surgery sixith edition 1157-1171,2006)
Umbilical cord hernia…cont
Conclusion:Hernia of the umbilical cord is a rare entity of the abdominal wall defects , y ,but , careful attention should be paid in order not to miss it.If there is any suspicion of an umbilical cord hernia , the umbilical clamp should , pbe applied distally to avoid injury of the contents.
Umbilical cord hernia…cont
Force should not be applied in pporder not to cause any damage to the bowel while reducing theto the bowel while reducing the contents, keeping in mind the possible causes of irreducibility.
suggest the presense of an umbilical mass , but other diffrentials can not be excludedbut, other diffrentials can not be excluded which might be an omphalocele , umbilical hernia with associated omphalomesenterichernia with associated omphalomesenteric duct (David M. sherer .Gynecol obstet Invest 51:66-68,2001) or an isolated patent51:66 68,2001) or an isolated patent omphalomesenteric duct (Jona JZ:congenital hernia of the cord and associated patent omphalomesenteric duct :a frequent neonatal problem ? Am J perinatol 1996;13:223-226.)
Umbilical cord hernia…cont
Differentiation from other abdominal wall fdefect should be kept in mind
umbilical hernia--- the defect is covered by a normal skin and is rarely present at birth , instead usually becoming apparent in the first weeks or months of life after the cord separation & epithelialization of the umbilical stump.
Umbilical cord hernia…cont
4 of the cases had wide base & long epithelialzed protrusion , were managed by repair of themanaged by repair of the umbilical hernia ( mayo s repair & cosmetic umbilicoplasty )
2 immediate2 immediate .2 late closure.
Umbilical cord hernia…cont
If the base is narrow & there is short protrusion ----------
d f hReduction of the contents & Simple l f hligation of the sac .
Umbilical cord hernia…cont
If the base is Broad & there is long epithelialized protrusion ------Initial reduction , lclamping &
immediate or later hrepair with cosmetic
umbilicoplasty